Employee Disciplinary Action Form

Section 1: Employee Information

Employee Name:_________________________________________ Date/Time of Offense(s):_______________________
Section 2: Type of Offense(s) (select all that apply)
Any Offense may result in suspension or termination, depending on the severity of the Offense(s) and damaged caused.
Suspension or Termination may be the result of multiple offenses on one occasion, harm to self or others, major property
damage, theft or other crime committed and/or it is a repeated Offense with one or more Disciplinary Action Form
Level 1 Level 2 Level 3 Level 4
[ ] Violation of [ ] Tardy for [ ] Calling in to inform the supervisor you [ ] No Call / No Show
dress code scheduled shift are not able to come in for a scheduled
shift without aqequate notice to find a
replacement within 24 hours.
[ ] Failure to [ ] Inappropriate [ ] Leaving workstation unattended [ ] Theft
complete paperwork electronic use
[ ] Excessive Visits [ ] Working out [ ] Unexcused absence from staff training [ ] Verbal/physical
from peers during your shift harassment
[ ] Insubordination [ ] Insubordination [ ] Improper behavior to a patron(s) [ ] Payroll fraud
or Misconduct or Misconduct
[ ] Insubordination or Misconduct [ ] Breaching
confidentiality
[ ] Insubordination
or Misconduct
[ ] Other (describe): _________________________________________________________
Section 3: Details (list facts only)
Describe what happened (List Facts, include details, damages, injuries, etc.) If more space is needed use the
back of this form

By signing this form you confirm that you understand the information above. You also confirm that you and the On-Duty
Supervisor have discussed the offense. Signing this form does not necessarily indicate that you agree with everything including
above.
On-Duty Supervisor signature : ________________________
Employee signature: ___________________________
On-Duty Supervisor printed name: _____________________
Employee printed name: _____________________________

Meeting with Facility Supervisor was conducted on: ___________________________________

Section 4: Employee Statement
[ ] I agree with the on-duty supervisor description of the volition
[ ] I disagree with the on-duty supervisors description of the violation for the following reasons: ( If more
space is need use the back of this form)
Section 5: Corrective Action Plan (if needed)

Section 6: Actions to be taken (if needed)

Consequences of this violation: [ ] Return to Duty [ ] Suspension [ ] Termination

Suppension From: ____________ To:_________________
By signing this form you confirm that you understand the information included. You also confirm that the employee and the On-
Duty Supervisor have discussed the offense and corrective action plan if needed. Signing this form does not necessarily indicate
that you agree with everything on this form.

Facility Supervisor signature : ________________________Employee signature: ________________________________

Facility Supervisor printed name: _____________________Employee printed name: _____________________________